Genital Tuberculosis

Dr Ajit Virkud Professor, and Head of Department, K.B.B.Hospital, Bandra, Mumbai. Consultant, Bhatia Hospital, Mumbai

Who said this? What was he referring to? “THERE IS A DREAD DISEASE…….. IN WHICH LIFE AND DEATH ARE SO STRONGLY BLENDED THAT DEATH TAKES THE GLOW AND HUE OF LIFE, AND LIFE THE GAUNT AND GRISLY FORM OF DEATH.” What was he referring to?

Answer Charles Dickens referring to Tuberculosis

Who discovered the Tubercle Bacillus?

Answer Robert Koch discovered the tubercle bacilli in 1882. The word tuberculosis was first used in 1834.

What was this disease called in ancient Indian Vedas?

Answer Tuberculosis was known as Raksyasman - king of diseases, in the ancient Indian Vedas

Who described the first case of genital TB? Who described the first case of TB endometritis?

Answer First recorded case of genital tuberculosis was described by Morgagni in 1744 First case of tubercular endometritis was reported by Kiwsch in 1847.

Which country has the highest incidence of TB?

Answer India has the highest incidence in the world. The reported incidence in India is 2- 10% (Malkani, 1975: 9.3%, Agarwal, 1993: 2.4%).

What is Mycobacterium tuberculosis complex? MTB complex?

Answer It comprises M. tuberculosis hominis M. bovis M. africanum (atypical Mycobacteria spp.) Tuberculosis in humans is mainly caused by bacteria called M. tuberculosis hominis (occasionally mycobacterium bovis or atypical tuberculosis organisms are also found).

How does TB bacillus differ from other bacteria? Why does it not respond to commonly used anti-bacterial agents?

Answer Tuberculosis organism is a non-motile obligate aerobe with replicating cycle of 17-24 hours (slow growing) It does not have a capsule. It has a property of being acid-fast due to the surface lipids. This property makes it resistant to common antibacterial agents and lytic enzymes.

How does Tuberculosis spread? Is it a sexually transmitted disease?

Answer Hematogenous spread: according to Magnus Hames this is the commonest mode of spread seen in 90% of cases. Descending infection (7%): direct or lymphatic spread from the peritoneum, bowel or mesenteric lymph nodes Ascending infection: rarely (1-2% cases) infection occurs from coitus with a male suffering from urogenital tuberculosis or by use of infected sputum as a lubricant for intercourse or in children who sit naked on infected sputum.

On PV examination F. Tubs are palpable? What is your diagnosis?

Answer Thickened, palpable fallopian tubes suggests tubercular salpingitis.

What is ‘frozen pelvis’? What is its differential diagnosis?

Answer When all pelvic structures are matted together and fixed with the uterus it results in frozen pelvis. DD of frozen pelvis? Florid genital tuberculosis Grade III/IV pelvic endometriosis Advance invasive carcinoma of cervix Following radiotherapy for invasive carcinoma of cervix

You are doing D & C to rule out TB endometritis. How do you obtain the endometrium and how do you send the sample?

Answer One must do a thorough curettage, including bothy cornual regions (common sites for TB endometritis) Entire endometrium is collected and divided in two parts: Half in for formalin: for histopathological examination to look for tuberculous granulomas. Other half in saline for smear / culture / guinea pig inoculation. Smear: Ziehl Neelson stain

How do you obtain a sample in adolescent unmarried girls? In virginal adolescent girls with s/s of PID one must rule out Genital TB.

Answer In unmarried adolescent girls menstrual discharge collected within 12 hours of onset of menses can be used for culture.

What are the different culture media used for TB?

Answer Various culture media used are Lowenstein Jensen medium (color malachite green), Dorset's egg, Petroff's, Tween 80, Dubois medium Colonies are cream colored, raised, coarsely granular; dry friable and rough with spreading edges suggests virulent forms. Culture report takes 3-6 weeks.

Is Guinea pig inoculation essential for diagnosis? Can you use any other animal for testing?

Answer Animal inoculation is the only investigation accepted as confirmatory evidence of TB: Smaller lab animals like mice can be used

Read this HSG What is your diagnosis?

Answer HSG showing ‘sperm head’ appearance suggesting TB salpingitis.

Read this hsg? What is your diagnosis?

Answer Moth eaten appearance suggestive of TB endometritis

Read this HSG? What is your diagnosis?

Answer Venous & Lymphatic Intravasation DD Genital TB False passage Hsg done during or just after menses Injection of dye in a patient with bilateral cornual block

Read this HSG? What is your diagnosis?

Answer Tobacco Pouch Appearance seen in genital TB

What are the HSG findings suggestive of pelvic tuberculosis ?

Answer: In F. Tubes Bilateral blocked tubes especially at cornual end Beaded appearance Irregular shaggy outline of tubes Golf club/ sperm head appearance: small sacculation at the filling end of isthmus/ampullary portion of tube Maltese cross appearance: in fibrotic stage-curved or straight pipe-like appearance of tubes with lack of normal tortuosity Multiple filling defects, diverticuli or extravasation in tubal wall

Answer: In F. Tubes Leopard skin appearance: the ampulla of the tube is partially filled with dye giving a speckled appearance Rosette: the distal end of the tube is filled with dye that has a rosette appearance Tobacco pouch appearance Straight thickened, rigid “pipe stem” tubes Hydrosalpinx/ pyosalpinx Calcification in tubes

Answer: In Uterus Moth-eaten appearance: irregular outline of cavity (TB endometritis) Intra-uterine adhesions (synichae) Venous/lymphatic intravasation of dye

What is ‘Blue Uterus Sign’? What is the role of laparoscopy in diagnosis of genital TB?

Answer Laparoscopy should be done carefully to avoid injury to adherent bowel loops; open laparoscopy is preferred. “Blue uterus” when chromopertubation test done with methylene blue Acute salpingitis: red, swollen edematous tubes Tiny tubercles 1-4 mm on surface of organs: tubes, uterus Hydrosalpinx, pyosalpinx Tobacco-pouch appearance Violin string adhesions Unilateral / bilateral TO masses Straw colored thick jelly like exudate in POD Fimbrial biopsy, peritoneal fluid may be taken to confirm the diagnosis

What are the usg findings suggestive of TB?

Answer Loculated ascites: The presence of fine lacy strands or particulate matter in fluid is due to thin fibrin strands Bilateral or unilateral tubo-ovarian mass

What is Mitchison & Grosset Hypothesis What was he referring to?

Answer Group I: Fast growing, neutral pH, aerobic PYRAZINAMIDE Answer INH, RFMSM Group I: Fast growing, neutral pH, aerobic Group II: Slow growing, intracellular, acidic Group III: Slow growing, neutral pH, hypoxic Dormant bacilli ANTI-TB DRUGS HAVE NO ACTION RIFAMPICIN THE BATTLE AGAINST TUBERCULOSIS CANNOT BE WON UNTIL DRUGS THAT CAN EFFECTIVELY KILL THESE DORMANT TUBERCULOUS BACILLI ARE FOUND.

Which drugs are used in the 4 drug short course treatment? Why are these drugs used?

Answer Drug Bactericidal activity Isoniazide Bactericidal in-vivo and in-vitro Rifampicin Pyrazinamide Selectively bactericidal Streptomycin

What are the doses of these 4 drugs? Can you give these drugs twice weekly? On what basis?

Answer Drug Dose (<50 Kg) Dose (>50 Kg) Twice wkly dose Isoniazid (Z) 300 mg 450mg (8-12mg / Kg 600-900 mg Rifampicin (R) 450 mg 600 mg Tab. 600 mg Pyrazinamide (Z) * 1500 mg 2000 mg 3000 mg Ethambutol (E) 1200 mg 2400 mg THE REASON WHY ANTI-TUBERCULOUS DRUGS CAN BE EFFECTIVELY GIVEN IN TWICE WEEKLY DOSES ALSO IS BECAUSE M. TUBERCULOSIS IS A SLOW GROWING ORGANISM (REPLICATING CYCLE OF 17-24 HOURS).

What is DOTS?

Answer WHO declared tuberculosis a global emergency in 1993. World health assembly (WHA) set two targets for TB control to be reached by 2000: Detection of 70% of all new sputum-smear positive cases arising each year Treat 85% of these cases successfully To achieve this WHO promoted a new effective TB control program based on five essential elements called the Directly Observed Treatment Short course (DOTS) strategy

Answer: The five elements are Continued political commitment from governments Case detection through quality-assured bacteriology Standardized short-course chemotherapy (mentioned in detail below) for 6-8 months involving directly observing the patient An effective drug supply and management system Monitoring and evaluation system for overall assessment of program performance.

Answer It is defined as supervised intake of drugs five times a week for 8 weeks (in India, the patient is observed to take the drug daily in the intensive phase) and then three times a week for 4 months. The patients are given fixed drug combipack. The observer should be accessible, acceptable and accountable.

What is DOTS plus strategy?

Answer Patients who have a relapse or failure are categorized into WHO category II. In the initial phase they are given intramuscular injections of streptomycin thrice weekly for two months along with four drugs of category I (RHZE) under direct supervision. This is followed by four drugs (RHZE) thrice a week for another month. In the continuation phase they are given three drugs (RHE) thrice a week for 5 more months under direct observation.

What is MDR & XDR TB?

Answer Resistance to one drug e.g. rifampicin or isoniazid is called drug resistant tuberculosis. Resistance to both main anti-tuberculous drugs is called ‘multi-drug resistance’ (MDR) whereas resistance to many drugs namely isoniazid, rifampicin, injectable amino- glycosides and fluroquinolones is called ‘extreme drug resistance’ (XDR). Drug resistant tuberculosis is treated as category IV with a DOTS Plus strategy

Answer Drug resistant tuberculosis is treated as category IV with a DOTS Plus strategy: comprising six second line drugs daily for six months followed by four drugs for the next 18 months in the continuation phase.

What are the reserve line of drugs used in treatment of TB?

Answer Drug <50 Kg >50 Kg Thiacetazone 150 mg Ethionamide 500 mg Cyclocerine 1000 mg Inj. Kanamycin Inj. Capreomycin Inj. Viomycin

What are the newer drugs used in the treatment of drug resistant TB?

Answer Fluoroquinolones: Ciprofloxacin (1500 mg/day), and Ofloxacin (400-600 mg/day) for 6 months Anti-leprosy drugs: Clofazine (100-200 mg/day) Beta-lactam antibiotics: amoxicillin+ clavulanic acid (Augmentin) Macrolides: azithromycin, roxithromycin, and clarithromycin

Management of Infertility in Genital Tuberculosis?

Answer Tubal reconstructive surgery is contraindicated because there is usually irreparable damage of tubes (cilia are destroyed) May result in reactivation and dissemination Those with infertility must be treated with medical treatment; and if this does not help artificial reproductive techniques may be considered. However one must remember that in the presence of TB endometritis, the results of embryo transfer are disappointing.

What is the role of surgery in treatment of genital TB?

Answer Only surgical treatment possible is extirpative surgery with bilateral salpingo-oophorectomy Anti-TB chemotherpy started 2 weeks prior and continued for 6 months post-operatively. Indications for TAH with BSO are: Failure of medical line of treatment progression or persistence of active tuberculosis Large T-O masses, pyosalpinx, pyometra or ovarian abscess in a symptomatic patient of perimenopausal age group.

Answer Contraindications to surgery: Active tuberculosis elsewhere in body Plastic peritonitis or dense adhesions around pelvic organs. During surgery: do not use non-absorbable sutures because of risk of fistula / sinus Vulvectomy may be required in cases of hypertrophic vulvar involvement.

What is the prognosis in genital TB cases as regards fertility?

Answer Prognosis for child-bearing is very poor; almost nil if endometrium is destroyed. Only 2-5% patients will conceive 20-30% will have spontaneous abortion 40-50% ectopic pregnancy Only 20% will go to full term Even after ART, the prognosis is poor especially if endometrium is destroyed

“ Tuberculosis Minded” If mankind is to win the war against tuberculous organism, it is imperative that world bodies like WHO, Stop TB Organization and TB Alliance should work together to develop new and effective anti-tuberculous drugs and vaccines. “ Tuberculosis Minded”

Thank You!